Form Ins. S.4-6/1 - Pre-Participation Physical Evaluation Form printable pdf download

CLEARANCE FORM

Bellevue Public Schools

Pre-participation Physical Evaluation

Name __________________________________________ Sex _______ Age _______ Date of birth _________________

Last

First

M.I.

Address ___________________________________________________________________________________________

Street

City

State

Zip Code

School:

Bellevue East High

Bellevue West High

Lewis & Clark Middle

Logan Fontenelle Middle

Mission Middle

Physician’s Section

Cleared for all sports without restrictions

Cleared for all sports with recommendations for further evaluation or treatment for:

___________________________________________________________________________________________________

Not cleared

Pending further evaluation

For any sports

For certain sports: ____________________________________________________________________

Reason: _____________________________________________________________________________

Recommendations: __________________________________________________________________________________

___________________________________________________________________________________________________

EMERGENCY INFORMATION

Allergies _______________________________________________________________________________________

Other Information ________________________________________________________________________________

I have examined the above-named student and completed the pre-participation physical evaluation. The athlete

does not present apparent clinical contraindications to practice and participation in the sport(s) as outlined above.

A copy of the physical exam is on record in my office and can be made available to the school at the request of the

parents. If conditions arise after the athlete has been cleared for participation, the physician may rescind the

clearance until the problem is resolved and the potential consequences are completely explained to the athlete (and

parents/guardians).

Name of physician (print/type) _________________________________________________ Date __________________

Address __________________________________________________________ Phone __________________________

Signature of physician ______________________________________________________________________, MD or DO

Physician’s office official stamp verifying exam:

Emergency Information/Permission To Treat

Parent/Guardian Name: ____________________________________________

Home Phone: ___________________

Day Phone #:

Father __________________________________

Mother ___________________________________

Cell Phone #:

Father __________________________________

Mother ___________________________________

Emergency Contact other than Parent/Guardian: Name ___________________________ Phone # _______________

School policy requires that all students participating in interscholastic athletics must be insured. The above named athlete is

insured against injuries that might be incurred during participation in interscholastic athletics and grants the

coach/sponsor/trainer permission to have their child treated in case of injury.

____________________________________________________

_________________________________________

Insurance Company

Policy group # and Individual #

Policy Holder’s Name: ________________________________

Employer: ___________________________________

Primary Care Physician: _____________________________________ Phone # _______________________________

Known Allergies and other conditions: (Asthma, diabetes, pervious head injury, surgeries, vision problems, etc.)

Form Ins. S.4-6/1 - Pre-Participation Physical Evaluation Form

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